Abses otak

Oleh

: Caroline M.(2003 61 182)

Christina Chandra (2007 61 066)
Magdalena Niken. (2007 61 145)

Pembimbing : dr. George Dewanto , Sp. S

Fakultas Kedokteran Atma Jaya 2008

Abses otak

Penimbunan nanah yang terlokalisasi

Selubung yang disebut kapsel.

Tunggal atau multiple

http://www.vetmed.wsu.edu/medsci520/images/ci27.jpg

Predisposing Conditions & Microbiology

Predisposing Condition

Usual Microbial Isolates

Otitis media
mastoiditis

Streptococci
Bacteroides and Prevotella
Enterobacteriaceae

Sinusitis

Streptococci, Bacteroides
Enterobacteriaceae,
S. aureus,
Haemophilus

Dental sepsis

Mixed Fusobacterium, Prevotella

Bacteroides streptococci

Trauma

S. streptococci,
or postneurosurgical
aureus, Enterobacteriaceae, Clostridium

Lung abscess empyema

Fusobacterium, Actinomyces,
Bacteroides and Prevotella

bronchiectasis

streptococci, Nocardia
Bacterial endocarditis S. aureus,
streptococci

Congenital heart disease

Streptococci, Haemophilus
Neutropenia gram-negative bacilli,
Aspergillus, Mucorales, Candida

Transplant

Aspergillus ,Candida ,Mucorales,

Enterobacteriaceae, Nocardia T.
gondii

HIV

T. gondii, Nocardia
Mycobacterium
Listeria monocytogenes,
Cryptococcus neoformans

 Bacterial
Fungal (aspergillus, candida, dll)
Protozoal and Helminthic

Bacterial Brain Abscess

Streptococci most commonly (70%)
Mixed infections (30% to 60%)
Streptococcus milleri group
Oral cavity, appendix, and female genital tract

Otopharyngeal infections ,
After neurosurgical or other medical procedures

Staphylococcus aureus for 10% to 15%

cranial trauma

 Bacteroides and Prevotella in 20% to 40%

mixed infection

Enteric gram-negative bacilli (e.g., Proteus

species, Escherichia coli, Klebsiella and
Pseudomonas) in 23% to 33%
otitic infection
Septicemia
neurosurgical procedures
immunocompromised

 rarely <1% of cases

Haemophilus influenzae
Streptococcus pneumoniae
Listeria monocytogenes
Immunocompromised 85%

facultative gram-negative organisms

Citrobacter diversus
Proteus
Serratia marcescens
Enterobacter

 Mycobacterium tuberculosis
Nontuberculous mycobacteria

Fungal Brain Abscess

Candida
most etiology
corticosteroid, broad-spectrum antibiotic
hyperalimentation

malignancy
neutropenia,
chronic granulomatous disease, DM

thermal injuries

 Aspergillus

rarely isolated brain infection

Lungs
paranasal sinuses
neutropenic in hematologic malignancy hepatic disease
Cushings syndrome
DM, CGD,
HIV ,injection drug abusers
postcraniotomy
organ transplant
corticosteroid

Protozoal and Helminthic Brain Abscess

Toxoplasma gondii
is the most common
Immunocompromised hosts

Trypanosoma cruzi
Entamoeba histolytica
Schistosoma
Paragonimus
Neurocysticercosis
Taenia solium

Pathogenesis
Contiguous focus of infection
most common

middle ear, mastoid cells, or paranasal sinuses.

otitis media : temporal lobe , cerebellum
Paranasal sinusitis : frontal lobe
sphenoid sinusitis: temporal lobe , sella turcica
molar teeth : frontal lobe

Hematogenous from a distant focus of infection

.
usually

multiple, higher mortality

chronic pyogenic lung diseases
lung abscess, bronchiectasis, empyema, and cystic
wound and skin, osteomyelitis,
pelvic infection

 Trauma
open cranial fracture with dural breach
neurosurgery or foreign body

Cryptogenic
Patent

foramen ovale

Four stages of brain abscess evolution

early cerebritis (days 1 to 3)

late cerebritis (days 4 to 9)

early capsule formation (days 10 to 13)

late capsule formation (day 14 and later

Early cerebritis stage

Acute inflammatory
infiltrate with visible
bacteria on Gram
stain and marked
edema surrounding
the lesion.
No contrast
enhancement

Late cerebritis stage

The center of the lesion

becomes necrotic,

Macrophages and
fibroblasts invade the
periphery

Proliferate blood vessel

surrounding lesion

Early capsule formation

necrotic center decrease in size
development of a collagenous capsule that is less

prominent on the ventricular side of the lesion

cerebral edema starts to regress during this stage.

Late capsule formation

The collagen capsule was complete
Circumferentially
Increased in density and thickness

The wall of abscess consists

MANIFESTASI KLINIK
Symptom or Sign

Frequency (%)

Headache

70

Mental State Changes

70

Focal Neurologic Deficits

>60

Fever

4550

Triad of Headache, fever

and neurologic deficits

<50

Seizures

25-35

Nausea and vomiting

25-50

Nuchal rigidity

25

Papilledema

25

Differential diagnosis of ring enhancing

cerebral lesions

Brain abscess

Primary or metastasis brain tumor

Subacute ischaemic infarction

Resorbing haematoma

Demyelinating disease

Diagnosis
Abses Otak

 CT Scan Otak
hypodense center surrounded by smooth,
regular thin-walled capsules with areas of ring
enhancement.
surrounded by variable hypodense area of brain edema

nodular enhancement
areas of low attenuation without enhancement,
during the early cerebritis

 Differentiation between pseudo-capsule and true

capsule may be achieved by delayed scanning
after IV contrast medium, in cerebritis stage the
centre of the lesion will fill in with contrast
medium, whereas with mature abscess, there is
never enhancement of the pus-filled centre.
thick or markedly irregular wall suggests a
tumor rather than an infective lesion

CT Scan Otak
a ring or doughnut representing spherical wall or
capsule of abscess
contrast enhancement being result ofbreakdown of
bloodbrain barrier and
hypervascularity of the granulation tissue
nonenhancing abscess centre is pus or nonviable
debris
commonly extensive edema of vasogenic type in
surrounding white matter.

CT Scan Otak
capsule is usually less well developed on
ventricular side than on cortical side.
useful for following the course of brain abscess
although after aspiration, improvement in the CT
appearance may not be seen for up to 5 weeks or
longer.

MRI

first imaging choice

more sensitive than CT
variable & change with the stage of abscess
therapy with corticosteroids can decrease
enhancement seen with both CT and MRI

Figure 1MRI of the brain showing lesions in

the lateral ventricle (red arrow), right parietal
(yellow arrow), and right occipital lobe (blue
arrow).

Figure 2MRI of the brain showing the

midline shift to the left (red arrow), with a mass
effect at the midbrain and the ventricular level.

Cerebral Tuberculoma

Figure 3

Cerebellar abscess and mastoiditis (contrast CT)

(Atas) Lihat proptosis

kanan disebabkan oleh
ekstensif varises orbita
media dan pembesaran
encephalocoele
intranasal para-median.
(Bawah) Perbaikan
sebagian dari proptosis
mengikuti pengobatan
sukses dengan
antibiotik.

CT scan menunjukkan varices orbita dan encephalocoele nasal. (b) CT Scan menunjukkan
encephalocoele menyebabkan obstruksi drainase maksila-antral. (c) CT scan menunjukkan
abses otak pada lobus frontal kanan. (d) Scan MRI koronal melalui orbita menunjukkan
encephalocoele dan formasi abses/serebritis ekstensif. (e) MRI sagital dari tulang belakang
menunjukkan empyema subdural intraspinal (anak panah)